National Agenda for Public Health Action:
A National Public Health Initiative on Diabetes and Women’s Health

Picture the Possibilities

What do we want? 

The National Agenda for Action is founded on a realistic vision and on specific and attainable goals.  These are consistent with the framework of Healthy People 2010, which establishes national targets that address primary prevention of diabetes and prevention of complications related to the disease.

Our Vision

• Diabetes among women can and should be prevented or at least delayed whenever possible.
• The families and communities of women at risk for diabetes can and should be informed and provided the support they need to prevent or delay diabetes and its complications.
• Appropriate care and management of diabetes can and should be promoted among women across the life stages.
• The complications of diabetes among women can and should be prevented, delayed, or minimized.

Our Goals

• We must garner the national attention of policy makers, public health professionals, other advocates for women's issues, researchers, and the general public to achieve the realization that diabetes is a prominent public health issue.
• We must develop consensus among key stakeholders that there is a need to establish priority strategies, policies, and research to improve diabetes and women's health.
• We must delineate the public health role in diabetes and women's health at national, state, and community levels and improve the capacity of these public health sectors to fulfill that role.
• We must unite partners from multiple sectors of society in a coordinated strategy to prevent and manage diabetes among women.
• We must empower women to adopt prevention strategies that will improve their overall health and delay or prevent diabetes and its complications.

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What are our guiding principles?

The guiding principles underlying the National Public Health Initiative on Diabetes and Women's Health are equally important. 

• A public health approach to diabetes among women should be adopted.  This approach aims to improve the health and quality of life for all women primarily through prevention and focuses on all factors that influence health status—physical, behavioral, psychological, and socioeconomic.
• Collaboration within and among multiple sectors of society is essential for success.  These sectors include public and private health care organizations, business and industry, education and environment, communication and media, and policy makers. 
• Strategies and policies must fully consider and take into account the unique needs of women in different life stages among all racial, ethnic, religious, and cultural groups.
• Women and grassroots organizations should be fully engaged as active partners in policy decisions and in program planning, implementation, and evaluation.  The strong involvement and support of men should be sought as well.
• Leaders of state and community agencies and groups must share accountability for adopting approaches to improve the health status of women. 
• Actions should be based on sound research from all relevant scientific fields, and the pursuit of additional public health research should focus on filling gaps in scientific knowledge.  Assessment must guide policy and program development. 
• Measurable outcomes for programs and policies should be established so that progress and impact can be evaluated and approaches can be modified as needed. 
• Strategies and policies must be sustainable and integrated over time and not just one-time interventions.  New initiatives should build on existing resources, services, and natural links between local, state, and federal agencies and organizations in both the public and private sectors.

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What is our public health prevention framework? 

The National Agenda for Action encompasses three approaches to prevention. 

• Primary prevention aims to prevent or delay diabetes in women.
• Secondary prevention aims to identify diabetes at its earliest stage so that prompt and appropriate management can be initiated.  Successful secondary prevention reduces the negative effect of diabetes on a woman's life.
• Tertiary prevention aims to reduce or minimize the consequences of diabetes once it has developed—that is, to eliminate, or at least delay and reduce, the onset and severity of complications and disability due to diabetes, such as blindness, kidney failure, and lower limb amputations.

The National Agenda also recognizes the unique challenges to prevent diabetes and its complications among women in different life stages.  We envision a shift in emphasis toward prevention strategies and activities appropriate to the needs of women at different life stages.  Fundamental to this shift is identifying and building on existing opportunities and programs for women across all life stages.

The adolescent years (ages 10-17 years) are marked by major biological and psychosocial changes that transform adolescents into adults.  Adolescents with diabetes face many life choices that can affect their ability to control the disease.  Peer pressure can undermine therapeutic goals for adolescents with type 1 diabetes and place them at increased risk for complications.  Primary prevention of type 2 diabetes is key at this life stage, as is instituting lifelong healthy behaviors related to physical activity and nutrition. 

The primary emphasis of public health action in the adolescent years is to improve the health and preventive practices among all youth, particularly among girls already diagnosed with or at high risk of developing diabetes.  To accomplish this goal, several major challenges must be overcome.  These include the following:

• Lack of diabetes education and prevention materials appropriate for adolescent females;
• Inadequate numbers of physicians who specialize in caring for this age group;
• Lack of quality physical education programs in schools;
• Lack of awareness of the need for weight control, healthy diets, and physical activity among adolescents;
• A plethora of fast-food and other unhealthy eating options; and
• Insufficient recreational activities and environments for youth (e.g., parks, sidewalks, and safe playgrounds).

Hope for the future is bolstered by recent school policy changes and better models for physical education and health education curriculum.  Successes with other diseases and health problems that might benefit diabetes prevention (for example, no-smoking campaigns), as well as more effective media messages and campaigns to raise awareness and promote healthy lifestyles, and advances in electronic and computer technology as a teaching tool all provide opportunities for prevention.

The reproductive years (ages 18-44 years) represent the life stage when women experience significant personal growth and increasing responsibility-additional schooling, marriage, career development, and child rearing.  Diabetes during pregnancy, regardless of type, puts both a woman and her unborn child at risk for negative health outcomes.  For those with few personal resources, this period can place them at high risk for negative outcomes and future economic hardship. 

Women face significant barriers to self-care in their reproductive years in the form of balancing the demands of marriage and other relationships, work, child care, household chores, hobbies, and so on.  The result is limited time for physical activity, healthy eating patterns, and attending to the woman's own health care needs.  In addition, many women reduce their level of physical activity during pregnancy and early postpartum.  Mothers may not lose the weight gained during pregnancy and thus put themselves at greater risk of obesity and of developing diabetes in later pregnancies or later in life.  Cultural, social, and physical environmental factors that influence these behaviors can also contribute to lack of self-care.  Confusion can result from conflicting health messages from a multitude of sources with regard to chronic disease prevention.

Overcoming these barriers requires taking advantage of unique opportunities to tailor messages to reproductive-aged women, capitalize on the intergenerational aspects of gestational diabetes, and include men and families as supportive partners.  Prenatal, postpartum, and other reproductive health services represent important vehicles for identifying and instituting preventive care for women at high risk for diabetes. 

The middle years (ages 45-64 years) are noted by major physiological events such as menopause.  This is also a time when other chronic diseases and complications of diabetes most often first appear, along with many other social and psychological challenges such as disability, death of a significant other or parent, divorce, and retirement.  Because women are increasingly developing diabetes at younger ages, complications are expected to develop earlier as well. 

During this life stage, some of the major barriers to preventing diabetes and its complications are similar to those in the reproductive years.  Prevention takes a backseat to treatment, particularly when acute health issues arise.  There may be a transition in health care providers, from gynecologists to family practitioners, internists, and specialists.  Women may have even less time to tend to their own needs as they assume care not only for their children and grandchildren but also for their aging parents. 

However, this role as the primary care giver, sandwiched between two generations, affords a rare opportunity.  The woman's sphere of influence is broader and deeper than at any other time in her life; she has the chance to be a role model for female relatives and friends.  Middle age is also the time when women are most active in civic and religious organizations, an ideal opportunity to deliver prevention messages, interventions, and support. 

The older years (ages 65 years and over) are at time when women with diabetes become even more vulnerable to other chronic illnesses, disability, poverty, and loss of social support systems.  The number of women in this age group is growing exponentially as the American population ages.

Health insurance barriers are compounded in this life stage, with the transition from employer-based coverage to Medicare and other private or public health insurance carriers.  The elderly also frequently experience isolation, depression, and lack of social support from their families and communities.  Prescription drug coverage is an issue, as is fragmentation of health care services.  Financial resources may be limited, particularly for those who rely on Social Security and have fixed incomes.  In addition, the number of elderly people from racial and ethnic minority populations who have limited English proficiency is increasing dramatically, with no comparable increase in the availability of culturally and linguistically appropriate health care services.  

Opportunities for prevention lie in the increased frequency of health care visits among the elderly for diabetes and comorbidities.  Although the actual face-to-face time with health care providers is limited, that time can be optimally used for meaningful education and motivational messages.  Community, civic, and religious organizations can also play key roles in promoting behaviors that improve health and quality of life.

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